A World Without Planned Parenthood?

Just after data was released showing a 50% decline in the number of clients served with family planning program funds, as a result of drastic budget cuts that created a de facto ban on participation by Planned Parenthood, the Texas Health and Human Services Commission on Oct. 18 said plans for the revamped Texas Women's Health Program are finalized, including an even more firm ban on participation by any PP clinic.

The state has sought to exclude PP, which has served on average more than 40% of program clients each year, on the basis that the clinics that serve TWHP clients are affiliates of PP clinics that provide non-program clients access to abortion care. Pregnant women are not eligible for the program, which is designed to decrease the number of unplanned pregnancies in the state that would be paid for by Medicaid – currently more than half of all Texas births. Federal law won't allow for the exclusion of qualified Medicaid providers, so the state has to pay for the program on its own – $36 million next year and $43 million in 2014 – in order to maintain the ban.

Now, women's health advocates are concerned that the women orphaned by the TWHP will not be able to find new providers. Health and Human Services Executive Commis­sion­er Dr. Kyle Janek told reporters on Oct. 18 that he is confident that as long as there's a "market" for this program, there will be enough providers. But Janek's optimism doesn't match up with the disappointing news family planning contractors received this week regarding the number of clients served from December 2011 through May 2012. According to the Department of State Health Services, just 90,237 women were served during that six-month period, 50% fewer than were served during the same period a year earlier.

Advocates had expected a decline after lawmakers last April cut by two-thirds the budget for the family planning program. Those cuts were also designed to defund PP, the largest network of specialty family planning providers in the state. When the cutting was finished, just $19 million per year over the biennium remained out of a two-year pot of roughly $100 million traditionally allocated to family planning. Since 2005, that budget had served an average of 244,000 women each year. But after the cuts, 53 clinics across the state – including many non-PP clinics – closed their doors, and 38 other clinics reduced their hours.

Fran Hagerty, CEO of the Women's Health and Family Planning Association of Texas, which has lost at least half its members as a result of the budget cuts, says the combination of slashing the family planning budget and the banning of PP from the TWHP means that there will be fewer non-PP providers left to absorb the TWHP clients.

In an effort to attract more doctors to the TWHP, the final rules for the program have softened a rule that would have prohibited doctors from any discussion of abortion with any clients, potentially even non-TWHP clients. The Texas Medical Associ­a­tion warned that instituting a "gag rule" would force doctors to ignore medical ethics in order to participate in the program. Janek said that doctors will be able to factually discuss abortion with TWHP clients and even provide a name of a doctor that performs abortions if asked. The rules were also revised to allow doctors who work in hospitals or as part of a physician group to participate even if a doctor they're associated with performs abortions.

Hagerty doesn't think this will be enough to compel enough private doctors to fill the void left by family planning clinics. Doctors may be hard-pressed to take on clients if they're not going to be reimbursed for other health issues that may come up along the way, but federally qualified health centers are bound by federal law to cover all of a patient's medical needs and not only "small batch" services, says Hagerty.

Overshadowing everything is a pending lawsuit filed by Planned Parenthood that challenges the constitutionality of the TWHP's ban on its participation. The final rules address that, too: If the suit is successful, the state will dismantle the program, which could leave more than 115,000 women without access to health care, and it will be up to the Legislature to sort it out, Janek said. Asked if he was concerned about what would happen to those women in such a case, he said, "That would be a question, bluntly, of what did they do before we had the waiver to begin with."